UPDATED_SCOPE_OF_WORK_TPA_WC_9_25_2025.docx

A. SCOPE OF WORK:

The successful Contractor must provide all personnel, labor, materials, supervision, travel, facilities, software, and equipment to provide TPA services in compliance with the County's scope of work which for all services required shall also include services requested and required by the Pinellas County Sheriff’s Office as a separate entity under the same umbrella. Contractor must provide a tollfree or local area code (727) number for member services. The successful Contractor must prepare all deliverables in such a manner that they shall be accurate, coordinated, or adequate for the purposes intended and in conformance with all applicable laws and regulations and within our preferred provider BayCare network.

a) Transition Duties -

1) The Contractor must provide the necessary support, including IT support, insight, guidance, and assistance to ensure a smooth conversion for all the County's WC claims which include claims involving Sheriff’s employees. The Pinellas County Sheriff’s Office will be a participant and will utilize this contract for their WC claims.

2) The Contractor must provide a mutually agreeable written transition Schedule for both County and the Sheriff’s Office claims.

3) The Contractor must provide a work plan that lays out an effective strategy for service transition and the data conversion.

4) The Contractor must hold joint data conversion review meetings with the County and the Pinellas County Sheriff’s Office. The first meeting must take place within one (1) week from issuance of notice to proceed. The Contractor must provide meeting agendas and meeting minutes for all such meetings.

5) The Contractor must ensure claim conversions are accurate with respect to data integrity, including but not limited to data mapping, historical financial transactions, and payment history and classification.

6) The Contractor must set up and train the County and the Pinellas County Sheriff’s Office team on Contractor's Risk Management and Insurance (RMI) System as requested by the County. The participants to be included in the County's team will be determined upon execution of a contractual agreement for services.

7) The Contractor must pick up files at a mutually agreeable date, if there are any paper files.

8) The Contractor must provide one experienced lost time adjuster to both the County and the Pinellas County Sheriff’s Office while Contractor completes the transition duties listed above.

b) Administrative and Managerial -

1) The Contractor must analyze, verify, and make payment of state fines and assessments, if/when appropriate. If the state fines and assessments are incurred based on the conduct of the Contractor, then the Contractor is responsible for payment of the state fines and assessment and shall not charge same to the County. If the County's actions are the basis for the fines and assessments, then the Contractor may charge those amounts back to the County.

2) The Contractor must provide assistance to the County, including all reports and data necessary, for filing annual certification of the County's safety program and drug-free workplace programs by October 31st of each year.

3) The Contractor must provide the County annual documentation of Contractor's State of Florida certification as a qualified servicing entity for self-insureds.

4) The Contractor must assist and coordinate with the County in filing Annual Payroll Report to the state including notifying the County that the report is due at least 60 days prior to the due date and advise the County of any changes or new requirements for the report.

5) The Contractor must provide WC claims data in the format requested by the County's actuary by October 15 of each year and provide any supplemental data as requested by the actuary.

6) The Contractor must coordinate and respond on the County's behalf to the state or federal government, including Occupational Safety Health Administration (OSHA) and the Center for Medicare Services (CMS) and any other audits or requests that may be required of or by the County, including investigating and responding to state's notification of late payments, related fines, and Inquiries on Special Disability Trust Fund and Permanent Total Disability cases.

7) The Contractor must provide responsive and professional account management, administrative services, information technology services, 1099 filing, subrogation and recovery services, Special Investigative Unit (SIU) services to investigate fraud and any other professional services per industry standards and claims handling best practices.

8) The Contractor must provide prescription, bill review -and payment services in a manner which allows the County to realize optimum savings.

9) The Contractor must pay benefits on time per state requirements and file all information required by the Division of Workers Compensation (DWC) per Florida EDI guidelines for all WC claims benefits and WC claim related expenses and is solely responsible for any fines or fees including but not limited to attorney's fees imposed against the County or employee as a result of any failure to timely pay.

10) The Contractor must provide documentation and summarize your firm's Emergency Management Plan to ensure the continuity of services after a catastrophic event that affects your operations.

11) The successful firm shall have and maintain a documented and successful Quality Assurance Program to ensure proper protocols are established and maintained for all claims processed.

c) Technical and Reports -

1) The Contractor must provide an information management system for the County (Risk Management Information System or RMIS) with the following capabilities:

a. Manage and store, in native format, all WC claims data, documents, and forms, including but not limited to medical records, payout sheets, transcripts, correspondence, notes, pleadings, orders, reports, voicemail messages when appropriate and any forms required by the State of Florida.

b. Create all automated reports required to be generated pursuant to this Agreement.

c. Provide 24 hour telephonic and internet-based claim reporting and intake capabilities. The Contractor must provide The County with the ability to report First Notice of Injuries electronically in real time, preferably with a telephonic 24-hour nurse hotline.

2) The Contractor must provide the County, including the County Attorney's Office, full access to the RMI System through an internet-accessed, secure website that is available 24 hours a day, 7 days a week for approximately 15 users. The website shall allow the County to view and obtain all data, payments, documents, and forms contained therein, to add notes to the adjuster or claim file that creates an automatic alert to the adjuster that such notes have been added, and to create automated and manual reports.

3) The Contractor must provide a toll free or 727 area code phone number, email address and fax number for use by the County to report new WC claims (in addition to a telephonic means of reporting claims) and forward documents received on existing claims.

4) Within twenty-four (24) hours of the County sending a new loss report, Contractor must provide the County with a claim number in the format requested by the County.

5) The Contractor must provide a toll-free/local number for County employees with questions on their claim to call.

6) The Contractor must provide check registers on a weekly basis as required by County.

7) The Contractor must have in place a system to support electronic reporting for State of Florida EDI & Federal Medicare Queries and Reporting.

8) The Contractor must have all technical services configured to meet ADA requirements.

d) Claims Management, Adjusting, Investigation, & Reporting -

1) The Contractor must provide professional WC claims administration, including: telephonic and field investigation, statements, photos, settlement evaluation, medical care management referrals, scheduling· of appointments, tests and notifications of same, medical cost containment, medical bill review and payment in accordance with Florida WC fee schedule and any additional discounts that may be due from the County’s preferred BayCare provider and/or the TPA's provider network and any further discounts negotiated independently by the County.

2) The Contractor must determine and make payment of indemnity benefits due and owing and provide electronic reporting of both indemnity and medical payments to the state.

3) The Contractor must maintain and administer one or more bank accounts for the payment of claims. Contractor must send monthly reconciliations and outstanding checks list to the County by the 15th day of the following month. Annually, Contractor will review the outstanding checks and identify stale dated checks outstanding greater than ninety days from the check date. The Contractor is responsible for compliance and remittances due under escheatment laws of any jurisdiction as they apply to claims paid under this agreement.

4.) County will remit payment to the Contractor via ACH or wire transfer weekly for claims paid. The Contractor must provide a weekly payment report in Microsoft Excel or other County approved format by 10:00 a.m. ET on Monday mornings indicating all claimants on a light duty or no duty status and any WC claims that have changed in the past 2 weeks from light duty or no duty to full duty. Report must include detailed information on the last 2 indemnity payments, with type of benefit paid, payee information, time period covered, date of check, payee, amount paid, temporary total disability rate (TTD), average weekly wage (AWN), temporary partial rate (TPR), customary work week, check number, date of loss, claimant name, current work status, date of current work status, claim number, and department. The County will pay Contractor for services under Section 5 of the Agreement through the County's normal vendor payment process.

5) The Contractor must provide an experienced litigation adjuster who can respond to a Petition for Benefits and ongoing communication with the County Attorney's Office or outside counsel, if any, attending mediations, depositions and trials when requested by the County, handling of subrogation, third party recovery, other adjuster claim services and maintaining files for all the County's WC claims.

6) The Contractor must manage an open, re-opened and new WC claims for the duration of the Agreement. Perform alive and well checks on all PTD claims.

7) The Contractor must consult prior paper files, if any, as part of its claims process and maintain all legacy paper files on pending WC claims received from the County in a secure and organized manner. Paper files shall be returned to the County in a secure manner when no longer needed.

8) The Contractor will receive the notice of claim from either an electronic telephonic reporting service or the County department and create claim files in Contractor's RMI System for each claim and maintain the file for the duration of the Agreement. Files reporting period shall be established per County's fiscal year and shall contain the County's hierarchy as provided and updated by the County. Files are the property of the County and information in same should be maintained and safeguarded per industry standards, state and federal requirements and as described herein.

9) The Contractor must provide an adequate number of experienced licensed lost time adjusters dedicated to the County's and the Pinellas County Sheriff’s Office WC claims to handle all matters in a timely manner. Additionally, the adjuster will be located on-site in the County's WC office Monday through Friday for 8 hours a day, the time to be established by the County and the Contractor. A WC adjuster will also be located onsite at the Pinellas County Sheriff;s Office at least one day a week. This adjuster will also act as the liaison for the County's WC administration office and be available to handle WC claim situations needing immediate attention.

10) The Contractor must investigate WC claims for compensability, validity and liability for subrogation purposes and provide field adjusters/investigations when necessary.

11) The Contractor must document the claim file clearly as it relates to all phone conversations, discussion or meetings.

12) The Contractor must ensure compliance with the County's drug free workplace program and if any drug testing is necessary, ensure proper protocols are followed to enable valid defense of WC claims.

13) The Contractor must determine compensability including securing the injured employee's recorded statement on lost time and on subrogation files and ultimately for investigating liability for subrogation potential. Contractor must secure recorded statements on WC claims involving ongoing lost time to confirm and limit injuries and secure information on prior accidents and injuries. Any subrogation recovery will be paid100% to the County.

14) The Contractor must provide courteous and responsive service to the injured employee and others involved in the claim process including Respond to claimant within one (1) business day and to physician's office within two (2) business days for all lost time cases. Respond to the County Attorney's Office or outside counsel, if any, within one (1) business day or same day if needed on WC claims with an active petition for benefits. County Attorney's Office or outside vendor will respond within the same time frame.

15) The Contractor must contact employee's supervisor or County's specified liaison when warranted to investigate WC claims as well as advising of claim status and ensuring proper work status. For the Pinellas County Sheriff’s Office, the contractor must contact the Human Resources Benefit’s Section.

16) The Contractor must coordinate any return of injured employees to light duty with employee's supervisor and contact the County for assistance as needed.

17) The Contractor must advise the County of any WC claim that may warrant additional loss control or safety investigation to aid in the prevention of similar losses in the future.

18) The Contractor must determine and process payments on the proper benefits due on compensable WC claims within one (1) business day prior to the due date under Florida Statute 440. Any full denial of compensability will be discussed with the County prior to proceeding with the denial.

19) The Contractor must confirm with the employer's payroll department that base wages were paid in full for the first 7 days of disability and report that time-period as employer paid in Electronic Data Interchange (EDI) report to the DWC. In some instances, the employer paid position is greater than 7 days.

20) The Contractor must apply the following Litigation management:

a. Work with the County Attorney's Office to 1) prepare a response and corresponding documentation for the defense of WC claims considered non-compensable, 2) respond timely to Petitions for Benefits on the Judge of Compensation Claims (JCC) website and 3) assist the County Attorney's Office or outside counsel, if any, in preparation of cases for hearings, appeals and mediations and attend same as requested by the County Attorney's Office or outside counsel, if any. Adjusters must be made available for depositions and meetings to prepare for depositions and attend mediations in person or via telephone or video conferencing at the discretion of the County or its legal counsel.

b. Coordinate investigation of any heart presumption cases, as defined by Fla. Stat. 112.18, with the County Attorney's Office or outside counsel, if any, regardless of whether the claimant is represented by counsel. The Contractor must not -file a denial without input from the County Attorney's Office or outside counsel, if any.

c. On cases with an active petition for benefits, timely notify the County Attorney's Office. or outside counsel. if any, of all activity relevant to the issue(s) in the petition for benefits including but not limited to when a claimant reaches maximum medical improvement (MMI), when a claimant's work restrictions have changed, when impairment ratings are assigned, and when a claimant has a change of physicians.

d. Work with the County to mitigate litigation and claim costs and promote settlements. All wash out settlements must be approved by the County in writing prior to the initiation of settlement discussions and once the file is settled it must be Medicare compliant.

e. Respond to requests for production and redact any protected information and/or qualifying employee data prior to submission. Have the County Attorney's Office or outside counsel, if any, review and approve and respond to the request for production.

f. Respond to requests for benefits, including requests for medical provider or service authorizations and other requests in a professional manner and within time requirements set forth in Florida Statute 440.

g. All correspondence to claimants' attorneys on cases with an active petition for benefits must be reviewed and approved by the County Attorney's Office or outside counsel, if any, before being sent, such review and approval does not diminish the Contractor's warranty pertaining to deliverables.

h. Prepare Special Disability Trust Fund submissions for reimbursement and follow up on same.

21) The Contractor must use Insurance Services Office (ISO's) Index service or other similar service to investigate employees on compensability and possible fraud matters. Report WC claims to ISO that involve lost time of more than a month·, any claims requested by the County, and any other claims that Contractor determines warrant an ISO filing. Respond to requests from other carriers for information based on ISO filings.

22) The Contractor must provide a cost-effective and an automated method for reporting WC claims to Medicare. Please describe what your current method is and how you follow up on queries and settlements.

23) The Contractor must schedule claims management meetings at a minimum of one time per month, with the County and the Pinellas County Sheriff’s Office separately, and as requested by the County within 3 business days for WC claims involving pending litigation, complex issues (large exposure flies, monetary or political) or questionable aspects (potential denials or fraud), and at the County's sole discretion.

24) The Contractor must file or, when the County is required to file an item itself, provide information and assistance as required for preparation and filing within the required timeframes of all reports required by the Florida Department of Insurance in connection with the County's approved self-insured status including but not limited to: the reports, procedures, and filings requested and/or required by the state for state audits. Chapter 440 and Chapter 682 of the Florida Statutes, the Florida Rules of Appellate Procedures, Section 6A-22 Reemployment Services, Section 59A-24 Drug Free Workplace Standards, Section 59A-29.009 Health Care Provider Certification, Section 59A-30.008 Expert Medical Advisors, Section 69L-3 on Workers Compensation Claims, Section 69L-5 Rules for Self-Insurers under the Workers' Compensation Act, 69L-6 Workers' Compensation Compliance, 69L-7 Workers' Compensation Medical Reimbursement and Utilization Review, 69L-10 Claim for Reimbursement Against the Special Disability Trust Fund, 69L-24 Workers' Compensation Insurers' standards and Practices, 69L-26 Employee Assistance and Ombudsman Office, 69L-56 EDI Technical Requirements,690-190 Rules for Self insurers under the Workers' Compensation Act, 60Q-6 Rules of Procedure for Workers Compensation Adjudications, and the Florida Administrative Code as applicable to Workers Compensation and Self-Insureds Statute.

25) The Contractor must file a Unit Statistical Report and file all EDI as required by the Florida Division of Workers Compensation.

26) The Contractor must advise the County of any claimant is reported late as defined in Chapter 440, Fla. Stat., to the Contractor by County departments.

27) The Contractor must meet all the requirements for Medicare reporting under Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), Section 111 and ensure that any and all settlements meet the Medicare conditional payment and future payment needs of the claimant.

28) The Contractor must advise the County of any Centers for Medicare & Medicaid Services (CMS) liens received and review the CMS liens received on pending and/or closed WC claims and respond to Medicare timely. Negotiate and resolve same.

29) The Contractor is responsible for working with the County for timely completion of the Unit Statistical Report to the Slate of Florida that requires a three-year history with an evaluation date of July 1st.

30) The Contractor does not have authority to settle or deny claims. Prior authority must be obtained from The County's Risk Department. The Contractor must provide recommendations for settling or denying claims, in writing with detailed reasoning.

31) In the event of termination of the agreement, it will be the successful Contractor's responsibility and obligation to handle all incurred claims at the time of its termination to their conclusion unless released from their obligation by the County.

32) The Contractor must be available to discuss claims directly with WC Program participants at their request.

B. INDEMINFICATION:

A. Contractor shall defend at its expense, pay on behalf of, hold harmless and indemnify the County, its officers, employees, agents, elected and appointed officials and volunteers (collectively, “Indemnified Parties”) from and against any and all claims, demands, liens, liabilities, penalties, fines, fees, judgments, losses and damages (collectively, “Claims”), whether or not a lawsuit is filed, including, but not limited to Claims for damages to property or bodily or personal injuries, including death at any time resulting therefrom, sustained by any persons or entities; and costs, expenses and attorneys’ and experts’ fees at trial and on appeal, which Claims are alleged or claimed to have arisen out of or in connection with, in whole or in part, directly or indirectly:

(i) The performance of this Agreement (including any amendments thereto) by Contractor, its employees, agents, representatives or subcontractors; or

(ii) The failure of Contractor, its employees, agents, representatives, or subcontractors to comply and conform with applicable Laws (as defined herein); or

(iii) Any negligent act or admission of Contractor, its employees, agents, representatives, or subcontractors, whether or not such negligence is claimed to be either solely that of Contractor, its employees, agents, representatives or subcontractors, or to be in conjunction with the claimed negligence of others, including that of any of the Indemnified Parties; or

(iv) Any reckless or intentional wrongful act or omission of Contractor, is employees, agents, representatives or subcontractors; or

(v) Contractor’s failure to maintain, preserve, retain, produce, or protect records in accordance with this Agreement and applicable Laws (including but no limited to Florida laws regarding public records).

B. The provisions of this paragraph are independent of, and will not be limited by, any insurance required to be obtained by Contractor pursuant to this Agreement or otherwise obtained by Contractor, and the provisions of this paragraph survive the expiration or earlier termination of this Agreement with respect to any claims or liability arising in connection with any event occurring prior to such expiration or termination.

C. COUNTY RESPONSIBILITIES:

1) The County and Sheriff’s Office will each provide a single point of contact to administer the agreement.

2) The County will work with the Contractor on any County issues that affects Contractor's timely performance per Florida Statute requirements.

3) The County will provide a programmer experienced with the County's current Risk Management system for assistance with the initial conversion process. Once conversion is complete and acceptable assistance will no longer be available.

4) The County will report all work Injuries to the Contractor utilizing a 3rd party vendor, like Company Nurse, or a similar company if Contractor does not have this feature.

5) The County will work with Contractor, when Contractor advises the County that an employee is released to light duty to assist in returning the employee to work within his/her restrictions, if possible. Currently, County Departments are required to provide light duty for a limited period of time.

6) The County Attorney's Office or outside counsel will represent the County as well as Appointing Authorities and Constitutionals, except the Clerk of Court, as outlined in 8 above, on all petitions for benefits and lien subrogation cases and advise Contractor of any additional investigation needed on any claim. The County will be responsible for any settlement offers. When the claimant's attorney wants to depose the adjuster, the County Attorney's Office or outside counsel will contact the adjuster to schedule the adjuster's deposition at a convenient time and will meet with the adjuster before any deposition of the adjuster.

7) The County will provide the wage information needed for Contractor to determine the amount of the WC benefit rate.

8} The County will work with the selected Contractor in regard to the "special handling instructions", which will be a live document that will be updated annually or as internal procedures/points of contact change.

9) The County may select specific vendors and develop pricing schedules for outside professional services.

10) The County will be responsible for sending the data provided by Contractor to the actuary for completion of the annual actuarial evaluation and report. County will be responsible for the actual submission of the payroll report to the State.

11) The County may be responsible for submitting the required annual defense attorney report to the State.

County will report annual defense fees for the County Attorney's Office and Contractor will report annual defense fees for any vendors.

12) The County will forward any authorization requests and any other correspondence to the Contractor within one (1) business day of receipt. County will be responsible for funding the account which the Contractor utilizes for claim payments.

D. SUMMARY OF INVOICES:

The Contractor must furnish the County, when requested, a detailed summary of invoices and summaries. The summary shall include an itemized description of services delivered and dollar amount of each. Failure to provide this information within 30 calendar days following the County's request may result in Contractor being found in default.

E. ACCOUNT MANAGEMENT:

Contractor must provide a single point of contact, dedicated account manager who will be readily available during normal business hours to administer the Agreement. Contractor is responsible for notifying the County with any changes in account manager or contact information. Account managers responsibilities shall include, but are not limited to, overseeing all aspects of implementation, servicing, reporting, and Issue resolution.

F. COMPENSATION AND OTHER DOCUMENTS TO BE RETURNED WITH SUBMITTAL:

The Contractor must include pricing for the following:

A flat annual fee that is inclusive of "Third Party Claims Administration•, establishing new claims/claim intake, EDI reporting to the state for indemnity and medical payments, EDI for compliance of Medicare queries and final claim determinations. ISO queries, the County and the Pinellas County Sheriff's Office use of data system(s) with up to 12 users, check writing and all other services required in the scope of services.

A. Provide a one-time price for transition of existing claims from the County and/or TPA current claims database(s) to Contractor's data base and assuming legacy/tail claims.

B. Provide pricing for additional services that are outside of the annual service fee lo include: bill review/repricing, Telephonic/Field Nurse case managers, pharmacy benefit management and any other ancillary services that Contractor provides such as surveillance, outside medical utilization review, outside medical management, costs of copies of public records or medical records; legal services, etc. All additional services will be accepted or declined by the County.

C. Successful firms Quality Assurance Program, how it operates, including benefits derived with examples of client success involved in this program.

G. SPECIAL HANDLING INSTRUCTIONS:

See Attachment 1 for workflows associated with Special Handling Instructions. Special Handling Instructions may be updated by as need with approval by County Risk Management staff.

H. SUMMARY OF PREFERRED QUALIFICATIONS:

Contractor shall:

A. Have a minimum of seven years’ experience providing TPA services for municipalities with both Police and Fire departments, as described herein, including a minimum of five years of secure internet access for same for the State of Florida Workers’ Compensation Claims.

B. Be a licensed TPA provider (not broker or agent) per Florida Department of Insurance regulations.

C. Provide evidence of financial stability and viability to fulfill the commitments of this Agreement.

D. Have the ability to obtain the minimum insurance requirements set forth in the Agreement.

E. Be free from legal and regulatory matters which might prevent the Contractor from fulfilling the obligations of the Agreement.

F. Be experienced with claims audits by the Division of Workers’ Compensation and have provided WC claims administration services to a minimum of two other Florida public entities.

G. Provide a dedicated account manager to function as the primary contact for all services and who has a minimum of two years’ experience with the firm.

H. The successful firm must have an established quality assurance program and possess significant experience working with governmental agencies including public safety personnel (police/fire etc.)

I. SUMMARY OF PREFERRED REQUIREMENTS:

Contractor shall:

A. Provide a toll-free telephone call-in number for County employee inquiries. The telephone call-in number shall provide access for hearing-impaired employees.

B. Provide an Internet accessed, secure website for purposes of obtaining account information and account management by the County’s Risk Management staff and legal counsel.

C. Have an office based in Florida, preferably in the Tampa Bay region, that will service the account.

D. Meet the time requirements established by the Florida Division of Workers’ Compensation for benefits and a minimum payment accuracy of 97% for all medical and indemnity payments.

E. Meet the time requirements established by the Florida Division of Workers’ Compensation statue and established case law including responses to all requests from authorized medical providers, claimants or their attorneys for authorization of medical care.